Medical History

January 30, 2008

Barack Obama's promise to move beyond partisan bickering has obviously given a lot of people hope. But, for those of us watching from the left, it's also been a source of concern. Oh, sure, it's nice when everybody in Washington gets along. But Obama's determination to embrace would-be adversaries sounds just a little naive, given the scorched-earth strategy Republicans and their lobbyist friends have waged against liberals in the last 15 years. Serious environmental regulation? Closing corporate tax loopholes? Major ethics reforms? As everybody from John Edwards to Paul Krugman has been saying, none of these are likely to become law without a fight.

And probably no fight will be bigger than the one looming over universal health insurance--which Obama, like his Democratic rivals, has promised to deliver. Since reformers of the Progressive Era first floated the idea of universal coverage in 1915, the goal has eluded four separate presidents. And the constant in this struggle has been the reflexive, ruthless hostility of conservatives and special interests, whether it was the American Medical Association slandering Harry Truman's coverage plan as "socialized medicine" in 1949 or the fictional TV characters "Harry and Louise" picking apart Bill Clinton's blueprint in 1994.

As it happens, Obama has his own history with health care reform. From 1997 to 2004, as a member of the Illinois Senate, Obama advocated several proposals to make medical care more accessible—culminating, three years ago, in a bill designed to force the creation of a universal coverage system for Illinois. And, while none of these efforts come even close in scale to what he's promised to try in Washington, they do provide a window into the governing style he would pursue there.

Time after time, Obama brought adversaries into the process early, heard out their concerns, then fashioned compromises many of them ultimately supported. In other words, he used the very strategy he's been describing on the campaign trail—the one giving people like me such angst. And yet, if you talk to liberals in Springfield, the ones who've spent decades fighting for universal health care, you don't hear a lot of disappointment with him. As far as they are concerned, Obama's signature inclusiveness was always a means to an end—a way to push the limits of reform rather than accept them. And, they say, it worked.

OBAMA HAS TAKEN plenty of heat over health care in this election, mostly over his decision to roll out a policy blueprint for universal health insurance that—although promising—seems less ambitious than those of his chief rivals. But, whatever the merits of his prescription, his commitment to making medical care more affordable isn't in question. Or, at least, it shouldn't be.

In 1996, when he first ran for state Senate, he indicated his support for universal health insurance—and a single-payer system, in which the government insures everybody directly (although he acknowledged it might not be feasible at the state level right away). Three years later, he was the lead Senate sponsor for the so-called Bernardin Amendment. Named after the famous Chicago archbishop, the amendment would have enshrined a right to health care in the Illinois constitution. Although a symbolic measure—the amendment did not specify what a "right to health care" entailed--it would have pressured the legislature to come up with some kind of coverage plan.

The amendment failed, but soon Obama was busy with a more concrete effort: expansion of public insurance programs to reach more of the uninsured. It was a tough political environment for trying such an initiative: Republicans, always skeptical of expanded government, controlled the state Senate. And they often did the bidding of the insurance industry, which didn't like public programs encroaching on its turf. So Obama sought common ground.

The result, according to John Bouman, director of the Shriver Center on Poverty Law, was two main compromises, including one allowing those newly eligible for Medicaid to opt for private insurance instead. It was a significant concession, since it gave the insurance industry a chance to compete for the new business. But it also undermined one of the best rhetorical arguments of critics, since it appropriated one of their favorite mantras: "choice." With that trope out of the way, Obama was able to fight for what he and the reformers thought mattered most: bringing insurance to a great many more people. And they won, prevailing over resistant conservatives. "He could not be accused of partisan aggression," says Bouman. "But he got his way."

In 2002, when Democrats won back control of the Senate, Obama became chairman of the Health and Human Services Committee. And it was from that perch that he adopted his other noteworthy health care cause, a measure called the Health Care Justice Act. The brainchild of grassroots activists tired of fighting losing battles to create a single-payer system for Illinois, the act, as originally proposed, would have created a task force, empowered it to develop a universal coverage plan, and then forced the legislature to vote on that plan. Predictably, it aroused the ire of insurers and other business interests, who, by all accounts, lobbied to derail the effort. "They—the insurers—pushed [Obama] really hard," says Jim Duffett, executive director of the Campaign for Better Health Care, the group championing the plan. "They also tried to use other people to push him really hard."

Publicly, Obama used hearings to rally voter support for universal coverage. Inside the statehouse, he pursued a two-track strategy. He made common cause with doctors and hospitals, two groups that had become more sympathetic to universal coverage because of the financial burdens charity care placed on them. This gave cover to moderates who wanted to support the bill, while increasing pressure on the insurers to fall in line. At the same time, Obama carried on discussions with the insurance and business lobbyists directly, eventually granting them two key concessions: He altered the makeup of the task force to make it more industry-friendly and dropped the provision requiring a vote from the next year's General Assembly. "We had significant concerns and looked to Senator Obama, who is an extremely bright and accessible individual," Phil Lackman, who represents the Professional Independent Insurance Agents of Illinois, told me. "My experience is that he is willing to listen to anybody willing to talk to him."

It's those kinds of statements that lead to stories, like one that The Boston Globe published in the fall, noting that "Obama's own experience in lawmaking involved dealings with the kinds of lobbyists and special interests he now demonizes on the campaign trail." But, whatever the contrast with Obama's campaign rhetoric, reformers in Springfield say the concessions worked out just fine. As it turned out, binding a future Assembly to vote on a measure was probably unconstitutional anyway. And the presence of insurance representatives on the task force may have actually bestowed it with additional legitimacy. Although those members would end up filing a dissent to the task force's final report—which was issued after Obama had moved on to the U.S. Senate—press attention focused on the majority recommendation. And that recommendation was just what many advocates hoped (and opponents feared) it would be: a comprehensive plan for universal coverage, financed and overseen by the state government. "He didn't back down," says Duffett. "There was no mandate [on the next Assembly to vote], but that was a constitutional issue. ... We got everything else we wanted."

Expanding Medicaid or creating a task force is not even in the same league as shepherding a bill that would, potentially, seriously reduce the profits of insurers, drug companies, and other health care industries. And so it would be foolish to think that, just because this strategy worked in Springfield, it would work in Washington, too. (It's worth noting that, despite the task force recommendations, Illinois actually hasn't enacted universal coverage yet.) But it would also be foolish to suspect that Obama equates compromise with capitulation. "Do not conclude that he does not have firm principled bottom lines--he does," says Bouman. "He doesn't compromise for the sake of it or because he's beaten. The talent is to achieve consensus on a good compromise and then push it through." Indeed. And while Obama's history can't tell us whether, as president, he'd push hard enough, it can reassure us that he understands pushing is necessary. That should count for something, even to a wary liberal like me.